Enroll a Student | STEM Velocity

You are Enrolling One Student in...

Note: Fields marked with a star (*) are required.

Student Enrolling in Workshop
Student Name *
Student Gender *	Girl Boy
Date of Birth *
Grade Level *	After the last day of school, select the rising grade and school.
Name of School *
Classroom/Teacher
Accommodations	e.g. allergies, food sensitivities, behavioral needs, learning techniques, transitioning time, proximity to facilitator, etc...
Parent/Guardian Information You must be a Parent or Legal guardian permitted to make decisions for the student indicated above.
First Name *
Last Name *
Address *
Home Phone *
Mobile Phone
Work Phone
E-mail *
	Please add me to your mailing list.
Emergency Contact
Full Name *
Relationship to Student
Phone *
Special Instructions Communication preferences, modified pickup times, other persons authorized to collect your student, etc...


How did you hear about us?	e.g. Search Engine, Referral, Brochure, etc...

Please check to box to indicate that you are a real person.